Members

     
 
 
 

Little Steps

Maternity Health Assessment
Please complete this confidential Maternity Health Assessment to help us consider your unique healthcare needs. A health coach will call you to discuss all the important steps you should be taking right now for a healthy baby later on.

If you have any questions, please contact us at (401) 459-2273 or 1-800-637-3718 ext. 2273.

Name:  
 
Date of Birth:  
 
Member ID:  
 
 
Address:  
 
  
 
  
 
  
 
City:  
 
State:  
 
Zip:  
 
Phone Number:  
 
 Alternate Phone Number:  
 
 Best day to call (Mon-Fri):  
 
 Best time(s) to call:  
 
   
Check any of the boxes below if they apply.  
   
Is this your first pregnancy?  
 
Do you have asthma or other  
breathing problems?  
 
Do you have diabetes or  
high blood sugar?  
 
Do you have depression?  
 
Do you have high blood pressure?  
 
Do you have any other  
medical condition?  
 
If yes, please explain:  
 
Do you take any medications  
or other home remedies?  
 
Do you smoke?  
 
What is your due date?